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Children Treated at an Expeditionary Military Hospital in Iraq ARTICLE Children Treated at an Expeditionary Military Hospital in Iraq Lt Col Christopher P. Coppola, USAF, MC; Maj Brian E. Leininger, USAF, MC; Lt Col Todd E. Rasmussen, USAF, MC; Col David L. Smith, USAF, MC Objective: To describe the treatment of children at an four (61%) of the 56 children for whom sex was re- expeditionary military hospital in wartime Iraq. corded were male. Injury was the diagnosis for 48 chil- dren (56%). Of these, the cause was fragmentation wound Design: Descriptive, retrospective study. in 25 children (52%), penetrating trauma in 11 (23%), burn in 9 (19%), and blunt trauma in 3 (6%). The site of Setting: The 332nd Air Force Theater Hospital in Balad, injury was the lower extremity in 18 children (38%), head Iraq, January 1, 2004, to May 31, 2005. in 11 (23%), upper extremity in 8 (17%), abdomen in 8 (17%), and chest in 3 (6%). Nontraumatic conditions had Patients: All 85 children (of 1626 total patients) evalu- congenital, infectious, gastrointestinal, and neoplastic ated and treated at the hospital during the study period. causes. During the study, 134 operations were per- formed on 63 children. There were 5 deaths. Interventions: Indicated surgical procedures per- formed on children. Conclusions: Expeditionary military hospitals will en- counter both injured and noninjured children seeking Main Outcome Measures: Age, sex, diagnosis, in- jury, operations, and complications for children during medical care. To optimize the care of these children, it the study period. will be necessary to provide the proper personnel, train- ing, and equipment. Results: The 85 children (age range, 1 day to 17 years; mean, 8 years) represented 5.2% of all patients. Thirty- Arch Pediatr Adolesc Med. 2006;160:972-976 ODERN WARFARE OC- II, forward surgical teams; level III, hos- curs in territories with pital facilities in the theater of combat; level a civilian population, IV, Landstuhl Regional Medical Center in resulting in injuries to Germany; and level V, Walter Reed Army noncombatants, in- Medical Center, Washington, DC.8 Mcluding children.1-6 Sometimes, children The level III hospitals in the theater of are employed as combatants or used as hu- combat are the highest-acuity facilities man shields.7 Therefore, it is inevitable that available to civilian casualties, including military medical units will encounter in- children. The absence of adequate na- jured children. Because local health care tional medical facilities creates difficulty is often disrupted near sites of conflict, chil- in discharging children from expedition- dren with other problems also may seek ary military hospitals if they have ongo- care at military hospitals. Just as it is im- ing medical needs.9 The lack of infrastruc- portant for military medical services to rec- ture, supplies, and personnel compromise ognize and prepare for traumatic injuries the effectiveness of Iraqi hospitals. Early incurred by combatants and noncomba- in the conflict, the decision was made to tants, it is also important to prepare for offer US military hospital care to injured medical illnesses that may be encoun- civilians in instances of life-, limb-, and vi- tered. sion-threatening injury. In addition, on a United States and coalition forces en- case-by-case basis, the hospital com- Author Affiliations: tered Iraq in 2003 and were accompa- mander could approve admission for chil- Department of Surgery, Wilford nied by medical personnel and facilities. dren with medical needs beyond the scope Hall Medical Center, Lackland Combat medical echelons of care are as fol- of the Iraqi civilian medical system. This Air Force Base, Tex. lows: level I, battalion aid stations; level report details a 17-month experience with (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 160, SEP 2006 WWW.ARCHPEDIATRICS.COM 972 ©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 60 Nontraumatic Traumatic 50 40 34 30 27 21 No. of Patients 20 10 3 0 Not Present Present Availability of Pediatric Surgeon Figure 1. The 332nd Expeditionary Medical Support Air Force Theater Figure 2. Children presenting to an expeditionary military hospital for Hospital in Balad, Iraq. The network of tents includes 3 operating rooms, traumatic and nontraumatic conditions during the 12 months before and the which can each accommodate 2 simultaneous operations. The adjoining 5 months after a pediatric surgeon arrived at the facility. helipad is visible in the background. 25 children treated at a level III expeditionary military hos- 25 pital in Balad, Iraq. 20 METHODS 15 11 10 9 This study is a descriptive, retrospective study, for which in- No. of Children stitutional review board approval was obtained from the hos- 5 3 pital command section. All patients presented to the 332nd Air 0 Force Theater Hospital in Balad, approximately 40 miles north Fragmentation GSW/SW Burn Blunt of Baghdad. The facility consists of a series of tents, linked by corridors, and a concrete floor (Figure 1). Figure 3. Mechanism of injury in 48 children treated at an expeditionary The structure includes metal containers used as operating military hospital. GSW/SW indicates gunshot wound and stab wound. rooms. In each of these 3 operating rooms, 2 operations can occur simultaneously, so that 6 procedures can be performed at a time. The hospital is capable of up to 24 intensive care unit recorded for 56 of the 85 children. Of these, 34 (61%) were beds and 80 ward beds, depending on how it is configured. A male, 21 (38%) were female, and 1 child with intersexu- multinational staff of approximately 420 personnel enables sur- ality had indeterminate sex. gical and medical care across numerous specialties. Overall, 48 (56%) of the 85 children were treated for a The period studied was 17 months from January 1, 2004, traumatic condition (ISS range, 1-29; mean, 8.5). The re- through May 31, 2005. This period was chosen because an elec- maining 37 children (44%) were treated for nontraumatic tronic record of all patients was initiated in January 2004 and diagnoses. From January 1, 2004, through December 31, the authors left the hospital in May 2005. Data were collected 2004, when no pediatric surgeon was present, 3 (10%) of from the surgical logs of the hospital and reviewed retrospec- 30 children were treated for nontraumatic diagnoses. From tively. The record included all patients presenting to the hos- January 1, 2005, through May 31, 2005, when a pediatric pital for care. The diagnosis was determined by the admitting surgeon was present, 34 (62%) of 55 children were treated surgeon. Demographic data were obtained from patients and Ͻ relatives, with assistance from translators, and recorded by the for nontraumatic diagnoses (P .001) (Figure 2). admitting nurse. Pediatric age was defined as being younger than 18 years. Data collected were age, sex, diagnosis, treat- INJURIES AND OTHER CONDITIONS ment, and complications. An International Classification of Dis- eases, Ninth Edition (ICD-9) code and Injury Severity Score (ISS) The most common cause of trauma was fragmentation were assigned for all children. The ISS was calculated using injury (25 [52%] of the 48 injured children) (Figure 3). ICDMAP-90 software (Tri-Analytics, Inc, Bel Air, Md). Statis- This category includes improvised explosive devices, un- ␹2 tical analysis was by for distributions and unpaired, 2-tailed exploded ordnance, indirect fire (mortars, rockets, and t test for numerical data. rocket-propelled grenades), mines, and blast injuries. Most of the children with fragmentation injury were injured RESULTS in improvised explosive device attacks. Most of the 48 injured children had multiple sites of injury, with the most The conditions of a total of 85 children were evaluated and common site of primary injury being the lower extrem- the children were treated during the study period, repre- ity (18 children [38%]) (Figure 4). senting 5.2% of all 1626 patients in the surgical logs and Nontraumatic conditions were grouped into the broad approximately 18% of the Iraqi civilians treated. Their age categories of those having congenital, infectious, gastro- range was 1 day to 17 years (mean age, 8 years). Sex was intestinal and feeding, and neoplastic causes (Table 1). (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 160, SEP 2006 WWW.ARCHPEDIATRICS.COM 973 ©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 18 Table 1. Nontraumatic Diagnoses in Children* 18 16 No. of 14 Diagnosis by Category (ICD-9 Code) Children 12 11 Congenital (n = 22) 10 8 8 Genitourinary (ambiguous genitalia [752.7], 3 8 hypospadias [753.8], cryptorchidism [752.89]) 6 No. of Children Hernia (inguinal [550.9], ventral [553.2]) 3 4 3 Vascular (228.01)/lymphatic (457.9) malformation 3 2 Craniofacial malformation (756) 3 0 CNS (encephalocele [742], meningomyelocele [741.93]) 2 Lower Head/Face/ Upper Abdomen Chest Thalassemia (282.49) 2 Extremity Neck Extremity Cardiac (hypoplastic left heart) (745.3) 1 Biliary atresia (751.61) 1 Figure 4. Primary site of injury in 48 children treated at an expeditionary Cystic fibrosis (277) 1 military hospital. Spondylolisthesis (756.14) 1 Calcific keratopathy (366.8) 1 Spastic contractures (718.4) 1 OPERATIONS AND OUTCOMES Infectious (n = 7) Visceral leishmaniasis (085.9) 2 Pneumonia (486) 2 At least 1 operation was required by 63 (74%) of the 85 Neonatal sepsis (771.81) 1 children examined at our hospital. A total of 134 opera- Infectious diarrhea (009.2) 1 tions were performed on 63 children (mean number, 2.1 Otitis media (382.9) 1 operations per child). These represented 4.4% of the 3036 Gastrointestinal/feeding (n = 5) total operations recorded at the hospital during the study Gastroesophageal reflux (530.81) 1 period. Forty-seven (98%) of the 48 children with trau- Rectal prolapse (569.1) 1 matic injury required an operation.
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